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7777 s.
<br />51.'I2I3(.:I [O3N S`t,)0:O3MPLE-FINCs FORM 'A'
<br />GENERAL IN4 FIZ7UC;"11ONS:
<br />°rt Al t" shall be completed for all t PERMITS, PERNirr C H ANO E-S or any ifACILI'tY,r"tl"YI
<br />;tm r 3N t"fI.:ANCiI�,S. '
<br />:: St_ltts`rvlfl' tINLY ONE () FO " ' For a I tchiiy/ t., . gardlcs~ of the s z n,Ei t .>t i.Fr l5 strcat c, a€ th, °is
<br />;s„ old las, completed by either the I'la.l mrr r�PP11S�°riNT or tits L.tJ�;IT, AGENCY t t;�'I�2>It(,1Z(3?. I>
<br />AN INSP I'ORL
<br />4._ Please type or print clearly all requested information.
<br />5. L Se a hard point writing instrument, you are making 3 copies.
<br />TOP OF IT )RME "MARK ONLY ONE T'I'EM"
<br />an (%) in tate box next to the item that best describes the reason the form is being completed, -
<br />Ia + ,1.,IyIY/ rrr INFORMN11ON & A11DRE&S (MUS-1' 1311. COMPLE-1.1,0)
<br />Record name and address (physical k,wastion) of the ua celg=,ound tank(s).
<br />NOTE: Address i41USI' have a valid physical location including arty, state, and kilo crack.
<br />nO). BOX Pv'I.I C.1EMS IOI NO'I' rA,C 0191 A1311°L
<br />Include nearest cross street and name of the. operator.
<br />2 Phone number must have an area code. If the night raumb=cr is the same, write SAME`' in proper lorzationt
<br />3, Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex, (:"C)i$C'ORA`I'IC)N, INDIVIDU Ai , etc.)
<br />4. Clfeck the appropriate box for TYPE OF BUSINESS,
<br />5. If Facility/Site is located within an. Indian reservadon or other Indian trust lands, check the box marked YES".
<br />6. Indicate the NUMBER ofTANKS at this SI"T[L
<br />7. Record the E.P.A. ID ffi or write "NONE" in the space provided,
<br />11. PROP(:IRrY OWNER iNiioRmxnoN & ADDIU�S: (kfusr BF COMP1.,L:"1 -,D)
<br />Complete all items in this section, unless all items are the sante as Si: C"THIN I; if the stune, write "SAME, AS ti9 n1, <rc n;ss
<br />this section. Be sure to check PROPERTY OIAVNERSHIP TYPE box.
<br />M. TNI{ OWNER INFORMATION & ADDRESS ( U51' Tilt C".C)a k'i.,LriED)
<br />Complete all items in, this section, unless all items are the same as ST^,C"1%C3N 1; If the same, write "SAME, rAS Srl'E across
<br />this section, Be sure to check TANK 1°.1:%1 'I'YP1- box,
<br />IV, BOARD OF 3'.C. UATI .fi11COIN i3 sr sroRAGE FEM lsC'C;4)UN117 NUMBER ER ( t3SI' BE (,'C)P1..1:11-53)
<br />Enter your Board of i qualiration (130F)UST storage Vo, account number which is required t>.l'c;ac, yon Jr pec ,at{it <sppl catictta
<br />can be processed. Registration veith the BOE wi l ensure haat you will receive a quarterly storage tee rcicas.n in rcpornng the
<br />$0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The 1300; will code persons exempt trona
<br />pa}ting the storage fee so returns will not be seri. If you do not have an account number with the 1101' or if you,ha�,e; anv
<br />questions regarding the fee or exemptions, please call the 130E at 916-323-9555 or write to the BOE, at: the following, address:
<br />Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001.
<br />V. PI, FROLEIJMI UW FAMN(I AL RF—SP NSIBH T (MTI° H,0M1,1 ,D)
<br />Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br />requirements. USTs owned by any Federal or State agency are exempt from this requirement.
<br />VL I..1IGAL NO3"I`H IC'.,tATIOIN AND BU .1NC1t DRESS
<br />Check ONE, BOX for the, address that will be used for B0114 I.La63 1 AND I3I1G N(YI'Llr1 ' °I10NS.
<br />. IPLIC'tANf MUST SIGN AND DATE `I1IE FORM AS INDICATIM.
<br />s1'ICYJCTnON FOR °I a LOCAL kAC'aI!N,NC IDS
<br />The county and jurisdi
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